How is Manual Lymphatic Drainage prescribed for Lymphedema and Lipedema?

Lipedema refers to a series of chronic illnesses. The symptoms and their associated issues can only be alleviated with consistent and long-term treatment. This is where conservative treatment in the form of complex decongestive physiotherapy (CDP) comes in. It consists of two stages: the decongestion stage and the maintenance stage. An important element in both stages of CDP is manual lymphatic drainage. However, many people who are affected do not have an easy time getting manual lymphatic drainage regularly prescribed. The following will explain why and will also discuss how manual lymphatic drainage is prescribed and the risks that might arise for patients.

Prescription within Lymphology

Manual lymphatic drainage is prescribed as a treatment by a doctor and carried out by a practicing therapist. During treatment, lymph circulation is encouraged and the edema (an excess of fluid collected in the cavities/tissue of one part of the body) is decongested. Manual lymphatic drainage is combined with compression treatment in order to achieve this and also to ensure that the edema does not spread.

However, medical guidelines do not make provisions for manual lymphatic drainage as a treatment for every type of lymphatic illness. This means that before 2017, patients with lipedema or secondary lymphedema in stages 1 to 3 were not able to readily get manual lymphatic drainage regularly prescribed.

The S1 Guidelines for lipedema which are currently in place describe manual lymphatic drainage as a possible main component in the reduction of edema and pain, whereas the current S2k guidelines for lymphedema designate manual lymphatic drainage as a standard treatment within CDP.

Treatments such as manual lymphatic drainage, physiotherapy, ergotherapy, etc. and their associated indications are listed in the catalogue of treatments. Prescribing these treatments, however, will debit the medical budget of the prescribing doctor; this means that there is an average amount of treatments that are usually prescribed and once a doctor prescribes more treatments than the average, he is threatened with financial recourse and must then make subsequent payments to cover the excess.

Usually, the typical case applies. In a typical case, provisions are made for a pre-determined number of prescriptions for treatment, which are debited from the medical budget of the prescribing doctor. This number is laid out in the catalogue of treatments. Once this number is reached, a minimum of 12 weeks passes in which no prescriptions can be made. In the case of edema, this is a long time; the illness can spread within this time period. However, if long-term treatment is required from a medical point of view, a doctor can issue a prescription outside of a typical case. The doctor must then provide justification to the patient's health insurance company.

Long-term treatment stipulations

Although the above system is in place, patients with stage 3 lymphedema and onwards, as well as those with hereditary lymphedema and lymphedema as a result of cancer are subject to long-term treatment stipulations. In this case, the medical budget of the prescribing doctor is not debited and prescriptions for manual lymphatic drainage can be issued outside of a typical case without prior approval. The only condition is that a new prescription must be issued every 12 weeks after a follow-up appointment with a doctor.

The treatment guidelines of the Joint Federal Committe (JFC) are regulated and outline what constitutes long-term treatment stipulations and which illnesses are included within this. The Joint Federal Committee consists of the Federal Association of Statutory Health Insurance Physicians, the Federal Association of Statutory Health Insurance Dentists, the German Hospital Federation and the National Association of Statutory Health Insurance Funds. Collectively, they regulate the services of health insurance providers in Germany.

According to the treatment guidelines, long-term treatment stipulations apply to illnesses that cause severe functional and structural damage, therefore requiring continuous treatment for a minimum of one year, e.g. congenital abnormalities (conditions that were inherited at birth) or serious metabolic disorders, such as cystic fibrosis.

The indications which have been set out for long-term treatment stipulations are contained within a diagnostic list. This diagnostic list can be found in an appendix to the treatment guidelines. As well as indications, this list also contains ICD-10 codes (e.g. I89.01 for lymphedema at stage 2). This diagnostic classification system acts as a coding system for all illnesses. Furthermore, the diagnostic list provides information about the assigned indication key for prescribing treatments (e.g. LY2a). This indication key provides information about treatment requirements and the maximum amount of treatment in a typical case, e.g. a maximum of 6 weeks per prescription for LY2a.

Long-term treatment stipulations for lymphological illnesses

After a decision by the Joint Federal Committee in 2016, the diagnostic list was expanded on 1st January 2017 to include the following lymphological indications (among others):

This means that for patients suffering from secondary lymphedema at stage 2 and other illnesses in the diagnostic list, a doctor can issue a prescription outside of a typical case, without having to explicitly justify it. The medical budget of the prescribing doctor is not debited.

When doing this, the doctor only needs to be aware that manual lymphatic drainage can be prescribed for a maximum of 12 weeks. A follow-up appointment with a doctor then takes place, in which a new prescription can be issued. The prescription must also contain the indication key and the correct ICD-10 code.

Since 2017, the ICD coding system also contains the cause of the illness, the area of the body in which the illness is located, and the degree of pain experienced in the case of lymphedema and lipedema. The ICD-10 codes have since been expanded from 4 digits to 5 digits for this reason. They are as follows:

When treatments are prescribed, the fifth digit of the ICD-10 code is important because this signifies whether the prescription is applicable to the medical budget. If a previous four-digit code (e.g. I89.0) is used, the stage of the edema is then not included in the prescription details, which means that the medical budget of the prescribing doctor applies and the treatment is then debited from this. However, if a new five-digit code is used, which is contained within the diagnostic list, this is instead not applicable to the medical budget. Current medical software can offer assistance in this regard; when the relevant ICD code is entered, the software will show you if long-term treatment stipulations apply.

These new changes are a great improvement for those suffering from edema; these changes allow doctors to provide a more nuanced diagnosis and therefore prescribe treatments that are more tailored to the patient's specific needs, without the medical budget of the prescribing doctor being debited. At the same time, the new coding system allows for a more detailed evaluation, which can benefit research into medical care. Furthermore, the new codes also require that the relevant stage of the illness is correctly diagnosed.
 

Long-term treatment stipulations for Lipedema

With the advent of the new ICD-10 coding system, lipedema is no longer listed under 'other types of edema' (with the code R60.9). This previously meant that the uneven distribution of fat could not be taken into consideration when a diagnosis was being made. The problem with this is that in the case of lipedema, an increase in subcutaneous fat cells (fat which is just below the surface of the skin, as opposed to visceral fat which surrounds the organs) is the main factor, and not the edema itself. Lipedema-related illnesses within lipomatosis (generalised increase in fatty tissue) is now classified under the new coding system.

This new coding system is still not perfect, however, and will be further optimised in the next version of the coding system (ICD-11), but a more precise diagnosis of lipedema is already possible. According to medical guidelines, manual lymphatic drainage is listed as a treatment option for lipedema to reduce the edema itself, to relieve pain, and to lower susceptibility to hematoma.

Despite this, the ICD-10 codes for lipedema are not included in the diagnostic list for long-term treatment stipulations. For those only suffering from lipedema, there are no special prescription requirements, i.e. prescriptions for manual lymphatic drainage are debited from the medical budget of the prescribing doctor. In this case, as is the case for other illnesses that are not included in the diagnostic list, an application for approval of long term treatment stipulations according to section 32 paragraph 1a of the German Social Security Code can be made to the health insurance company. The prescription must be enclosed with the application and the doctor must demonstrate in the application how severe and long-lasting the functional damage is, the limitations that the illness poses for the patient, and what level of treatment is required.

Once the application has been submitted, the health insurance company has 4 weeks to make a decision to either approve or deny. If there is no reply from the health insurance company within this period, the application is automatically classified as being approved. Once approval is given from the health insurance company, the patient can then receive manual lymphatic drainage outside of a typical case, as is the case with other patients who are suffering with illnesses not included in the diagnostic list.

If lymphedema is present in addition to lipedema, the patient is suffering from lipo-lymphedema. Under these circumstances, manual lymphatic drainage can be prescribed without the medical budget of the prescribing doctor being debited and without going through the approval process.

In this case and for other hybrid illnesses, two fields for the diagnostic key have been included in the prescription form for treatments since 2017. This means that doctors can enter both the ICD code for lipedema and lymphedema, so that (depending on the stage of the lymphedema) a prescription which does not debit the medical budget of the prescribing doctor can become possible if necessary.